TABLE 1. THE TEMPLATE S METHODOLOGY

CLINICALDEVELOPMENT Reducing overcrowding on student practice placements REFERENCES Channel, W. (2002) Helping students to learn in the clinical environment. Nursing Times; 98: 39, 34. Department of Health (2000a) Recruiting and Retaining Nurses, Midwives and Health Visitors in the NHS: a Progress Report. London: DoH. Department of Health (2000b) The NHS Plan: A Plan for Investment, a Plan for Reform. London: DoH. Duffin, C. (2002) Practice placements must improve, warns regulator. Nursing Standard; 17: 14 15, 8. Harrison, S. (2004) Overcrowded placements hinder student learning. Nursing Standard; 18: 22, 7. AUTHOR Roger James, MSc, DipHE, RMN, RGN, is preregistration nursing education coordinator, South West London and St George s Mental Health NHS Trust. ABSTRACT James, R. (2005) Reducing overcrowding on student practice placements. Nursing Times; 101: 48, 28 32. The UK is facing a major shortage of registered nurses. One government strategy for addressing this shortage has been the nationwide increase in the nursing student population. Large student cohorts have resulted in placements being overcrowded with students and, as a consequence, the quality of learning experiences has diminished. A mental health NHS trust in London in partnership with local higher education institutes has created a framework to relieve the pressure on placements. This article discusses the implementation of the framework and outlines the results, challenges and recommendations. Since 1997, the UK government has significantly increased the number of nursing student places (Department of Health, 2000a) in order that the nurse recruitment targets of The NHS Plan can be achieved (DoH, 2000b). However, the increase in student numbers has resulted in placement areas being overcrowded and, as a consequence, mentors having to accommodate more students than they can effectively support (Harrison, 2004). The role of practice placement facilitators, along with creative increases in the number of placements available, has helped to counteract the problem of student overcrowding within placement areas. Nevertheless, some areas in the country have now reached their maximum placement capacity (NMC, 2004a). Therefore, the problem of too many students for too few placements has not yet been resolved. Concerned that student overcrowding was affecting the quality of the students learning experiences within its practice settings, South West London and St George s Mental Health NHS Trust created a framework to address this problem. Entitled the James Placement Template, this framework is managed by the preregistration nursing education coordinator for the trust, in partnership with the placement teams at the local higher education institutes. Anecdotal evidence indicates that as a result of the template s implementation, student overcrowding within placement areas is now a thing of the past. The template s methodology is consistent with the regulatory requirements of the NMC, such as students spending 50 per cent of the programme within practice settings and placements facilitating direct contact with patients. Unlike the system that preceded it, and consistent with the higher education institutes curricula, the template also ensures that by the end of the programme all mental health nursing students have undertaken the same variety of placements. TABLE 1. THE TEMPLATE S METHODOLOGY SEMESTER ACUTE (A) ENDURING (E) OLDER PEOPLE (O) COMMUNITY (C) SPECIALIST (S) Year 1, semester 1 ( 11 ) A 11 E 11 O 11 Year 1, semester 2 ( 12 ) O 11 A 11 E 11 Common Foundation Year 2, semester 1 ( 21 ) 0.3 x E 11 0.3 x O 11 0.3 x A 11 O 22 + A 22 E 22 Year 2, semester 2 ( 22 ) 0.7 x E 11 0.7 x O 11 0.7 x A 11 O 21 + A 21 E 21 Year 3, semester 1 ( 31 ) O 11 A 11 + E 11 Final Placement Branch Nigel Hillier/UNP 28

KEYWORDS Placements Education TABLE 2. A TRANSLATION OF THE METHODOLOGY SEMESTER ACUTE ENDURING OLDER PEOPLE COMMUNITY SPECIALIST Year 1, semester 1 1 27 28 54 55 81 Year 1, semester 2 55 81 1 27 28 54 Year 2, semester 1 28 35 55 62 1 8 9 27 36 54 Year 2, semester 2 36 54 63 81 9 27 1 8 28 35 63 81 55 62 Year 3, semester 1 55 81 1 27 28 54 Final placement Common Foundation Branch REFERENCES (2004a) NMC News; 8: 5. London: NMC. (2004b) Standards of Proficiency for Pre-registration Nursing Education. London: NMC. (2004c) NMC Backs Skill Labs to Improve Student Nurse Training. NMC press statement. London: NMC. Pollard, C., Hibbert, H. (2004) Expanding student learning using patient pathways. Nursing Standard; 19: 2, 40. Background In nursing, practice placements are where nursing students apply their knowledge to practice and learn key skills to achieve the required competencies for registration (RCN, 2002). Preregistration nursing programmes comprise 50 per cent practice and, under current regulatory requirements, students have to complete 2,300 hours of practice in direct contact with patients (NMC, 2004b). In addition, higher education institutes and placement providers have to place students in accordance with the particular placement requirements of their curricula as well as operating within the framework of placement audits. Despite the challenges of these placement requirements, the nursing profession has generally welcomed the increase in student numbers in order to achieve the nurse recruitment targets of The NHS Plan. However, the increase in student numbers has resulted in the student population overcrowding practice placements and, as a result, mentors feeling overwhelmed (Harrison, 2004). The quality of the learning opportunities for students in practice has also been diminished by overcrowded placements (Duffin, 2002). Such is the current situation that the Nurse Directors Association has expressed concern to the NMC about the rise in student numbers placing unprecedented pressure on the availability of suitable placements (NMC, 2004a). Nevertheless, the current problem of too many students for too few placements has led some programme providers to find new and creative ways of structuring placements. Examples of creative measures that have been adopted by some higher education institutes and placement providers include: Patient pathways (Pollard and Hibbert, 2004); Client attachment (Turner et al, 2004); The WORLD model (Channel, 2002). WORLD stands for Working clinically, Observing practice, Researching a topic, Learning packs and Departmental visits. While all three models are different in their approach, the one thing they have in common is that they have been developed in response to rising student numbers the same reason the template was developed locally. Local context The local placement overcrowding mirrored the national picture. Within a three-year commissioning cycle, the annual number of mental health students increased by 45 per cent. During this period, there were more students than there were available placements. As a result, many students struggled to have quality time with their mentors, as areas that had been audited for two students were, at times, having to accommodate four. It has been recognised that overcrowded placements could have a detrimental effect on the students ability to integrate the knowledge, skills and attitudes needed to achieve fitness for practice (UKCC, 1999). The increase in the number of commissioned students and the need to ensure that placements contribute to the development of students fitness for practice were both contributory factors that led to the creation of the template. Placement allocation systems Health education institutions and practice placement facilitators use manual or automatic systems for allocating students to placement areas. Manual databases tend to be readily available on most computers in the workplace, but using them can be Royal College of Nursing (2002) Helping students get the best from their practice placements. London: RCN. Turner, L. et al (2004) Evaluating the introduction of a pilot client attachment scheme in mental health nursing education. Journal of Psychiatric and Mental Health Nursing; 11: 4, 414 421. United Kingdom Central Council for Nursing, Midwifery and Health Visiting (1999) Fitness for Practice: The UKCC Commission for Nursing and Midwifery Education. London: UKCC. This article has been double-blind peer-reviewed. For related articles on this subject and links to relevant websites see www.nursingtimes.net 29

TABLE 3. EXAMPLE OF THE ROTATIONAL SYSTEM OF ALLOCATION FOR NINE STUDENTS SDT YEAR 1 YEAR 1 YEAR 2 YEAR 2 YEAR 3 YEAR 3 1 Acute Enduring Older People Community Specialist Final placement 2 Acute Enduring Community Older people Specialist Final placement 3 Acute Enduring Community Older people Specialist Final placement 4 Enduring Older People Acute Community Specialist Final placement 5 Enduring Older People Community Acute Specialist Final placement 6 Enduring Older People Community Acute Specialist Final placement 7 Older people Acute Enduring Specialist Community Final placement 8 Older people Acute Specialist Enduring Community Final placement 9 Older people Acute Specialist Enduring Community Final placement time-consuming when allocating students to placements. Automatic systems, on the other hand, do require an additional financial outlay but are very comprehensive and cover several aspects of administration for higher education institutebased programmes. Both manual and automatic systems have benefits and limitations. Mathematical methodology The template has been developed from the creation of a mathematical methodology. This methodology was created using the following figures: The annual number of commissioned mental health nursing students; The placement capacity (based on placement audits) within local mental health services; Percentages of the placement categories within each semester. These percentages are based on the total number of placements available. The placement categories used in the template are derived from the mental health nursing curricula at the local higher education institute. These placement categories are: Acute = placements in acute admission wards; Enduring = placements in rehabilitation, continuing care and day hospital settings; Older people = placements in older people s settings; Community = placements in community mental health, assertive community treatment, early intervention and home treatment teams; Specialist = placements in forensic, addiction, child and adolescent, deaf mental health, eating disorders and psychological therapies. The definitions of the letters and numbers used in the mathematical methodology of the template are: Total number of students for placements = N Number of students in acute placement, year 1, semester 1 = A 11 year 1, semester 1 = E 11 year 1, semester 1 = O 11 Number of students in acute placement, year 1, semester 2 = A 12 year 1, semester 2 = E 12 year 1, semester 2 = O 12 Number of students in acute placement, year 2, semester 1 = A 21 year 2, semester 1 = E 21 year 2, semester 1 = O 21 year 2, semester 1 = C 21 year 2, semester 1 = S 21 Number of students in acute placement, year 2, semester 2 = A 22 year 2, semester 2 = E 22 year 2, semester 2 = O 22 30

year 2, semester 2 = C 22 year 2, semester 2 = S 22 year 3, semester 1 = C 31 year 3, semester 1 = S 31 It must be noted that the final placement (year 3, semester 2) is not included in the template s methodology. This is because, locally, final placements that occur within the last three months involve an element of choice. Thus, the wide variety of placements where students can be placed within this period makes it impractical to include the final placements within the template s framework. The methodology of the template developed to reduce student overcrowding in placement areas is: N 3=A 11 = E 11 = O 11 A 12=O 11 E 12=A 11 O 12=E 11 A 21=0.3 x E 11 E 21=0.3 x O 11 O 21=0.3 x A 11 A 22=0.7 x E 11 E 22=0.7 x O 11 O 22=0.7 x A 11 C 21=O 22 + A 22 S 21=E 22 C 22=O 21 + A 21 S 22=E 21 C 31=O 11 S 31=A 11 + E 11 A diagrammatic expression of the template s methodology is shown in Table 1, p28. There is a 30/70 percentage division of the cohort between year 2, semester 1 and year 2 semester 2. This division is necessary due to the current local availability of placements within the acute, enduring and older people categories. However, if placement availability alters in the future, it may become necessary to have a 40/60 or a 50/50 cohort division during the two semesters in year 2. For the template s methodology to be effective, N must equal a number divisible by three. For example, if the commissioned number of students is 80, this number can be increased to 81. The template s methodology can then be translated into the diagram shown in Table 2, p29. Similarly, a graphic illustration of the percentages of the local placement categories utilised in each semester is shown in Fig 1, p32. Ensuring accuracy and transferability In order to ensure the accuracy and transferability of the template, there are certain constraints to the diagram shown in Table 2, p29, that must be met. These constraints are: Each column must add up to N; Each row must add up to N; In each semester, all students must have a placement; All students need to complete every component of the broad placement categories; In each semester, no placement category must have more students than the capacity will allow. It is possible therefore to explore other placement patterns utilising the template, as long as the above constraints are met. Alternative placement patterns can occur as a result of: Differences in the number of commissioned students; Differences in the number of placement categories required, as stated by the curriculum; Variety in the number of placements available within the required categories. For example, the template can be used if N equalled 99 students and the curriculum required students to undertake only four placement categories. Rotational system of placement allocation The template s methodology ensures that overcrowded placements are prevented by operating a rotational system of placement allocation. This means that students in the same cohort undertake placement categories in a different order from that of their peers. By the end of the programme, all students would have undertaken the same placement categories. Table 3, p30 shows an example of the rotational system of placement allocation for nine students. The necessity to rotate students through placement categories is a result of increased student numbers and its ripple effect of overcrowded placements. Therefore, if the pressure of overcrowded placements is to be relieved, students in the same cohort will not be able to undertake placement categories at the same time. To a large extent, this is what already occurs at many higher education institutes across the country. Therefore, the template is a formalisation of this placement rotational system. Individual placement lines Apart from reducing student overcrowding within placements, the template will enable programme providers to develop individual placement lines for each student for the full duration of the programme. Determining exactly where each student is likely to be allocated for the full duration of the programme will enable higher education institutes to give students advanced notification of higher education institute placements. This will give students sufficient time to make personal arrangements with regard to 31

FIG 1. PERCENTAGES OF LOCAL CATEGORIES IN EACH SEMESTER 100 80 60 40 20 0 Y1 S1 Y1 S2 Y2 S1 Y2 S2 Y3 S1 Acute Enduring Older people Community Specialist childcare, travel and accommodation if necessary. It is acknowledged that, should individual placement lines have to be changed due to ward closures, changes to capacity and so on, this may leave students feeling disappointed. It is therefore imperative that students are informed that individual placement lines are provisional, subject to availability at the time. Nevertheless, few can argue a case for not giving advanced notification of placements to students, if it is possible to do so. The development of individual placement lines will also allow programme providers to repeat the same framework each year. Hence, as long as the placement pattern of the higher education institute s curriculum remains the same, or there are no significant reductions in placement capacity, time and energy could be saved by not having to find placements for each student for each semester. Results Since its implementation, the impact of the template on local overcrowding of placements is as follows. First, no placement area now has more students than its audited capacity. This is significant since, prior to the template s implementation, many placement areas accommodated double their capacity for students. Second, the template ensures that all placement experiences allow students to have direct contact with patients. This is consistent with the NMC s requirements which, in contrast to the Nurse Directors Association, call for the students experience in skills labs to be counted towards their practice hours (NMC, 2004c). However, there is a difference between pretending to carry out a function and the reality of placements. Finally, the template allows all students to undertake the same variety of placement categories over the course of the programme. This was not guaranteed before the template s implementation. For example, large student cohorts and the placement system at the time resulted in some students repeatedly undertaking community placements, while other students in the same cohort were unable to have one community placement. Challenges and recommendations Despite the template s results locally, it is acknowledged that circumstances in the future may jeopardise its effectiveness. For example, if there were further substantial increases in the number of commissioned students or if the number of students recruited was above the agreed commissioned number, the template s effectiveness would be undermined. It is therefore important that the placement capacity within the template is maximised by including not only public sector placements but also those in the independent and voluntary sectors. In addition, a reduction in the local placement capacity or significant changes to the design of the mental health curricula would also affect the template s ability to be an effective framework for relieving overcrowded placements. Thus it is imperative that the communication framework that exists between the trust and local higher education institutes is maintained and enhanced so that such potential problems can be prevented. The strategic health authority, the higher education institutes and managers on placement areas now have the assurance that placement areas will not have to accommodate more students than their audited capacity. As a result, it can be assumed that mentors are in a better position to offer quality learning experiences to students. However, objective evidence for this assumption is required. Thus, a study is to be undertaken with mentors and students to determine whether the reduction in student overcrowding has resulted in tangible improvements in the quality of learning experiences for students. 32